Blood Product / Massive Transfusion Record

ANESTHESIA DEPARTMENT • FORM F-12 • CBAHI/JCI COMPLIANT

Patient Name:	MRN:	DOB:	Age/Sex:	Weight: kg
Procedure/Surgery:			Location: OR ICU ER Other
Date: Time Started: Surgeon: Anesthesiologist: Blood Bank Contact:

🩸 1. TRANSFUSION INDICATION & PRE-TRANSFUSION ASSESSMENT

Indication for Transfusion

Surgical blood loss ( mL)

Trauma

Massive hemorrhage

Obstetric hemorrhage

GI bleeding

Coagulopathy

Sepsis/DIC

Other:

Massive Transfusion Protocol (MTP)

MTP NOT activated

MTP ACTIVATED - Time: By:

Code: Red (Trauma) Purple (Obstetric) Orange (Pediatric)

Clinical Context

Est. Blood Loss: mL | Bleeding: Controlled Active Severe

Surgical control achieved: Yes Partial No

Pre-Transfusion Vitals & Labs

Time:

BP: mmHg

HR: bpm

SpO₂: %

Temp: °C

Hb: g/dL

Hct: %

Plt: ×10⁹

INR:

PT:

aPTT:

Fib: g/L

pH:

Lact:

Ca²⁺:

Patient Blood Type

ABO: A B AB O | Rh: Pos Neg

Ab Screen: Neg Pos (specify):

💉 2. BLOOD PRODUCT ADMINISTRATION LOG

Product Details	Unit 1	Unit 2	Unit 3	Unit 4	Unit 5	Unit 6	Unit 7	Unit 8	Unit 9	Unit 10	Unit 11	Unit 12
PRODUCT TYPE
Unit Number
Start Time
End Time
Volume (mL)
Verified By
Nurse Initials

Product Legend: PRBC=Packed Red Blood Cells | FFP=Fresh Frozen Plasma | PLT=Platelets | Cryo=Cryoprecipitate | WB=Whole Blood

⏱️ 3. INTRA-TRANSFUSION MONITORING

Parameter	Time 1	Time 2	Time 3	Time 4	Time 5	Time 6	Time 7	Time 8	Time 9	Time 10
TIME
BP (mmHg)
HR (bpm)
SpO₂ (%)
Temp (°C)
UOP (mL/hr)
Nurse Initials

🔬 4. LABORATORY MONITORING

Lab Test	Baseline	Time 1	Time 2	Time 3	Time 4	Time 5	Target Range
TIME
Hb (g/dL)							>7-10
Hct (%)							>21-30
Plt (×10⁹/L)							>50-100
INR							<1.5
PT (sec)							<18
aPTT (sec)							<40
Fibrinogen(g/L)							>1.5-2
pH							7.35-7.45
Lactate(mmol/L)							<2
Ca²⁺ (mmol/L)							>1.0
Temp (°C)							>35

💧 5. FLUID MANAGEMENT & RESUSCITATION

Crystalloid Administration

Normal Saline: mL

Lactated Ringer's: mL

Other: Type: mL

Total Crystalloid: mL

Colloid Administration

Albumin 5%: mL

Albumin 25%: mL

HES/Gelatin: mL

Total Colloid: mL

Fluid Balance

Total Input: mL

Total Output: mL

Urine Output: mL

Blood Loss: mL

Net Balance: mL

Warming Measures

Fluid warmer Forced-air Humidifier Warmed IV

Patient temp maintained: Yes No

⚠️ 6. TRANSFUSION REACTIONS & COMPLICATIONS

No reactions observed

Acute Reactions

Febrile non-hemolytic (>1°C rise)
Time: Prod: Act:

Allergic/Urticaria
Time: Prod: Act:

Anaphylaxis
Time: Prod: Act:

Acute Hemolytic
Time: Prod: Act:

TRALI
Time: Prod: Act:

TACO (fluid overload)
Time: Act:

Bacterial Contamination
Time: Act:

Hypothermia (<35°C)
Time: Act:

Hyperkalemia / Hypocalcemia / Acidosis
Value: Act:

Coagulopathy / Other
Time: Act:

IMMEDIATE ACTIONS:
Stopped IV Open Bank Notified Unit Returned MD Notified Samples Sent

📊 7. MASSIVE TRANSFUSION PROTOCOL SUMMARY

MTP Round	Time	PRBC	FFP	PLT	Cryo	Ratio (PRBC:FFP:PLT)	Notes
Round 1
Round 2
Round 3
Round 4
Round 5
TOTALS

Target: Trauma (1:1:1) | OB (1:1:1 + Cryo) | Optimal Ratio Achieved: Yes No

💊 8. ADDITIONAL PHARMACOLOGIC INTERVENTIONS

Time	Agent	Dose	Route	Indication	Given By

TXA Calcium Protamine Vit K rFVIIa PCC DDAVP

✅ 9. TRANSFUSION OUTCOME & SUMMARY

Transfusion Outcome

MTP Terminated:

Reason: Bleeding controlled Hemostasis Death Coagulopathy corrected Other

Patient Status: Stable Improved Ongoing Resus Transferred Expired

Total Products & Final Labs

PRBC: U

FFP: U

PLT: U

Cryo: U

Hb: | Hct: | Plt: | INR:

✍️ PROFESSIONAL SIGN-OFF

Anesthesiologist
Name/Date:

Transfusion Nurse
Name/Date:

Surgeon/Physician
Name/Date:

Blood Bank Officer
Name/Date:

Form F-12 | Blood Product / Massive Transfusion Record | Version 1.0 | Page 2 of 2 | Medical Record - Permanent
MMU.5 (Blood Management) • COP.5 (Transfusion) • IPSG.1 (Patient ID) • ACC.3 (Assessment) • CBAHI/JCI Standards